Inspection·March 9, 2022

F 0679 Level of Harm - Minimal harm or potential for actual harm be reported to him within the online maintenance system. He reviewed the report on his work phone in the system, and the Maintenance Director stated the report was unable to be printed due to not having access to the program on another computer. He stated the only maintenance system request for Resident #4's room was in October 2021 related to painting. The Maintenance Director stated he has been considering installing more outlets, but it is not something that has been started yet. Residents Affected - Few 2. A review of Resident #13's admission Record revealed medical diagnoses, including but not limited to, a need for assistance with personal care, muscle wasting, and unsteadiness on feet. The resident's Minimum Data Set (MDS), dated [DATE], revealed the resident has a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. A review of the resident's care plan revealed an activities focus area initiated on 01/12/2022 with interventions including Prefers/would benefit from: In Room, The resident's Activity Assessment, dated 12/26/2021, revealed passive activities the resident enjoyed participating in included Watching TV. A description of the resident's favorite activities included [Resident #13] Favorite activities are . Watching Television . Talking with family on cell phone. Additional comments included the resident being independent, alert, and able to choose activities without facility intervention. An interview on 03/08/2022 at 12:24 p.m. with Resident #13 revealed the resident lying in bed watching television. The resident stated there were not enough electrical outlets around her bed. So, for her to use the TV she has to unplug her phone charger. However, she cannot let her phone die because then she cannot speak with her children. Additionally, the bed cannot be unplugged because then it cannot be adjusted. Photographic evidence was obtained of Resident #13's electrical outlet availability at the bed side. 3. An interview on 03/08/22 at 12:36 p.m. with the Director of Nursing revealed the residents have an Activities Assessment completed. The Activities Director would be responsible for assisting in implementing the resident activities and their activity preferences. A policy review of Activity Assessment, effective October 2021, revealed To obtain a current and historical activity profile and assessment for a resident centered activity program. This assessment will be used on all residents upon admission. This assessment will be reviewed quarterly, and with a significant change. Changes will be documented in a narrative section of the Progress Notes . Interview the resident or resident representative, review the Psychosocial History and Assessment, history and physical, physicians progress notes, dietary assessment to obtain historical and current information and preferences. A policy review of Activities Overview, effective October 2021, Activities Department employees will provide activities that include sensitivity and an understanding of each individual resident's needs and requirements including medical, emotional, spiritual, therapeutic, and recreational needs. The Activity Programs will reflect individual needs and provide/promote . personal responsibility, and choice . Activities will be provided at a frequency to meet the individual needs of the residents. Programs are designed to meet the interests and the physical, mental, and psychosocial well-being of each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105714 If continuation sheet Page 2 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer blood pressure medications according to the physicians ordered blood pressure parameters for two residents (#2 and #33) of seven residents reviewed for unnecessary medications. Residents Affected - Few Findings included 1) Review of Resident #2's admission Record revealed she was admitted to the facility on [DATE] with diagnoses to include cerebrovascular disease and hypertension. Review of Resident #2's current physician orders revealed an order for Amlodipine Besylate tablet 5 milligrams (mg) give 1 tablet by mouth twice a day for hypertension. Hold for B/P (blood pressure) systolic <120 and or a diastolic <70. This order started on 7/18/2021 and was discontinued on 3/1/22. Review of the Resident #2's February 2022 Medication Administration Record (MAR) revealed she was administered Amlodipine Besylate 5 mg eight times when her blood pressure was not within the physicians' ordered parameters. On 2/8/22 at 9:00 a.m. the documented blood pressure (B/P) was 104/60, medication signed off as given. On 2/15/22 at 9:00 a.m. the documented B/P was 134/60, medication signed off as given. On 2/4/22 at 5:00 p.m. the documented B/P was 124/68, medication signed off as given. On 2/13/22 at 5:00 p.m. the documented B/P was 126/68, medication signed off as given. On 2/20/22 at 5:00 p.m. the documented B/P was 120/64, medication signed off as given. On 2/22/22 at 5:00 p.m. the documented B/P was 124/64, medication was signed off as given. On 2/23/22 at 5:00 p.m. the documented B/P was 118/60, medication was signed off as given. On 2/24/22 at 5:00 p.m. the documented B/P was 128/68, medication was signed off as given. Review of the March 2022 MAR revealed on 3/1/22 Amlodipine was discontinued and reordered on 3/1/22 for Amlodipine Besylate tablet 5 mg give 1 tablet by mouth two times a day for hypertension with no parameters. Further review of Resident #2's current physician orders revealed an order for Carvedilol tablet 6.25 mg give 1 tablet by mouth two times a day for hypertension hold for B/P systolic <120 and/or diastolic <70. This medication was ordered to start on 7/18/2021 and was discontinued on 3/1/22. Review of Resident #2's February 2022 MAR revealed she was administered Carvedilol 6.25 mg ten times when her blood pressure was not within the physicians' ordered parameters. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105714 If continuation sheet Page 3 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 On 2/8/22 at 9:00 a.m. the documented B/P was 104/60, medication signed off as given. Level of Harm - Minimal harm or potential for actual harm On 2/15/22 at 9:00 a.m. the documented B/P was 134/60, medication signed off as given. On 2/19/22 at 9:00 a.m. the documented B/P was 108/66, medication signed off as given. Residents Affected - Few On 2/4/22 at 5:00 p.m. the documented B/P was 124/68, medication signed off as given. On 2/13/22 at 5:00 p.m. the documented B/P was 126/68, medication signed off as given. On 2/17/22 at 5:00 p.m. the documented B/P was 110/68, medication signed off as given. On 2/20/22 at 5:00 p.m. the documented B/P was 120/64, medication signed off as given. On 2/22/22 at 5:00 p.m. the documented B/P was 124/63, medication signed off as given. On 2/23/22 at 5:00 p.m. the documented B/P was 118/60, medication signed off as given. On 2/24/22 at 5:00 p.m. the documented B/P was 128/68, medication signed off as given. Review of the March 2022 MAR revealed on 3/1/22 Carvedilol was discontinued and reordered on 3/1/22 for Carvedilol 6.25 mg give 1 tablet by mouth two times a day for hypertension with no parameters then discontinued on 3/4/22. Review of Resident #2's care plan revealed an initiated date of 2/18/2021 for Cardiovascular: the resident has a cardiovascular problem r/t [related to] diagnosis of hypertension. Goal: Will be free from complications of cardiac problems through the review date. Interventions included but not limited to: Administer medications as ordered. Vital signs ordered (Refer to orders for current order). Observe for signs and symptoms of hypotension. Review of Resident #2's physician progress note dated 3/4/22 indicated diagnosis of essential hypertension. Continue Amlodipine Besylate tablet, 5 mg, 1 tablet, orally, twice daily. Stop Carvedilol tablet, 6.25 mg, 1 tablet with food, orally, twice a day. Notes: .blood pressure under control on current regimen. Based on staff report. Will reduce blood pressure medication. Continue to monitor blood pressure daily . History of present illness . Nursing staff at [Facility] have spoken to me about possibly adjusting patients' blood pressure medications they state that they have not had to give her blood pressure medication almost the entire time she has been at the facility. Her blood pressure ranges anywhere from 99/54-134/60 on average, staff state this is without blood pressure medications I will go ahead and adjust as appropriate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105714 If continuation sheet Page 4 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2) Resident #33's admission Record revealed he was admitted to the facility on [DATE] with diagnoses, including but not limited to, hemiplegia and hemiparesis following cerebrovascular disease affecting left non-dominant side, and hypertension. Review of Resident #33's February 2022 MAR revealed an order for Losartan Potassium Tablet 25 mg give 25 mg by mouth one time a day for hypertension. Hold for B/P systolic pressure <120. Order date of 2/1/21 and a discontinued date of 3/4/22. Further review of Resident #33's February 2022 MAR revealed he was administered Losartan 25 mg nine times when his blood pressure was not within the physicians' ordered parameters. On 2/1/22 the documented B/P was 110/74, medication signed off as given. On 2/4/22 the documented B/P was 102/62, medication signed off as given. On 2/6/22 the documented B/P was 118/68, medication signed off as given. On 2/10/22 the documented B/P was 108/60, medication signed off as given. On 2/11/22 the documented B/P was 102/64, medication signed off as given. On 2/13/22 the documented B/P was 102/64, medication signed off as given. On 2/14/22 the documented B/P was 118/70, medication signed off as given. On 2/15/22 the documented B/P was 110/68, medication signed off as given. On 2/23/22 the documented B/P was 113/60, medication signed off as given. Review of Resident #33's February 2022 MAR revealed an order for Nifedipine ER Tablet extended release 24 hour give 30 mg by mouth one time a day for hypertension hold for SBP [systolic blood pressure] < 120. Ordered date was 1/19/22 with no end date. Further review of Resident #33's February 2022 MAR revealed he was administered his Nifedipine 30 mg four times when his blood pressure was not within the physicians' ordered parameters. On 2/3/22 there was no blood pressure documented but medication was signed off as given. On 2/8/22 the documented B/P was 100/65 medication signed off as given. On 2/9/22 the documented B/P was 104/68 medication signed off as given. On 2/22/22 the documented B/P was 118/78 medication signed off as given. Further review of the February 2022 MAR revealed an order for Metoprolol Tartrate tablet 25 mg give 25 mg by mouth two times a day for hypertension hold for SBP < 120. In February 2022 Metoprolol 25 mg was administered twelve times when his blood pressure was not within the physician's ordered parameters. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105714 If continuation sheet Page 5 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 On 2/3/22 at 9:00 a.m. there was no documented B/P, medication signed off as given. Level of Harm - Minimal harm or potential for actual harm On 2/8/21 at 9:00 a.m. the documented B/P was 100/65, medication signed off as given. On 2/9/21 at 9:00 a.m. the documented B/P was 104/68, medication signed off as given. Residents Affected - Few On 2/22/21 at 9:00 a.m. the documented B/P was 118/78, medication signed off as given. On 2/1/22 at 5:00 p.m. there was no documented B/P, medication signed off as given. On 2/4/22 at 5:00 p.m. the documented B/P was 102/62, medication signed off as given. On 2/9/22 at 5:00 p.m. the documented B/P was 104/68, medication signed off as given. On 2/10/22 at 5:00 p.m. the documented B/P was 108/60, medication signed off as given. On 2/13/22 at 5:00 p.m. the documented B/P was 102/64, medication signed off as given. On 2/15/22 at 5:00 p.m. the documented B/P was 110/68, medication signed off as given. On 2/23/22 at 5:00 p.m. the documented B/P was 113/60, medication signed off as given. On 2/28/22 at 5:00 p.m. the documented B/P was 114/61, medication signed off as given. Review of Resident #33's care plan revised on 12/6/2018 revealed Resident #33 had hypertension r/t (related to) lifestyle, medications, stroke, receives antihypertensive medications daily. Goal: Will remain free of complication related to hypertension through review date. Interventions include but are not limited to: Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension and increased heart rate and effectiveness. Review of Resident #33's physician note dated 3/4/22 revealed: Stop Losartan Potassium tablet, 25 mg, 1 tablet orally, once day Stop Metoprolol Tartrate tablet, 25 mg, 1 tablet with food, orally, twice a day. Continue Nifedipine ER tablet extended release 24-hour, 30 mg, 1 tablet on empty stomach, orally, once a day. Notes: monitor for hypertension/hypotension/bradycardia. Report any worrisome clinical symptomatology such as sudden onset shortness of breath, severe headache, new onset neck pain, chest pain, weakness, fatigue, dizziness, syncope. History of present illness: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105714 If continuation sheet Page 6 of 7 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105714 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Concordia Manor 321 13th Ave N Saint Petersburg, FL 33701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few .Staff also bring to my attention that patient has multiple blood pressure medications ordered with parameters. They state that patient consistently does not receive his blood pressure medications and is going on for many months if not longer. They state patient's blood pressure us typically anywhere from low 100 systolic to 120 systolic. They asked that I look at his medications and adjust them is possible . An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 03/07/22 at 2:40 p.m. She stated Residents #2 and #33 consistently have low blood pressures but people will still give them their blood pressure medications out of range. The Administration will educate us, but the resolution is to remove the parameters when these residents have low blood pressure the nurses just need to follow the physicians' orders. An interview with the Director of Nursing (DON) was conducted on 03/09/22 at 11:29 a.m. she stated we have to take the blood pressure before we give the medication, and the medication should be given per the physician's orders. A phone interview was conducted with Resident #2 and #33's Advanced Practice Nurse Practitioner (ARNP) on 03/09/22 at 10:19 a.m. he stated he was at the facility on 3/4/22 and my recommendations were to stop Resident #2's Coreg [Carvedilol] and continue her Amlodipine. Her parameters should not have been removed from the order. Both Resident #2 and #33 have a history of being hypertensive and I want the nurses to have something in the event their blood pressure is high but, I don't want them to give the blood pressure medications if they are running low that is why the parameters should be there. I have been a nurse for 8 years and that is nursing 101 to take the blood pressure before giving a blood pressure medication to ensure it is being administered appropriately. The DON brought it to my attention the nurses were not taking the blood pressures before administering the medications for both Resident #2 and #33 and I nicely told her, well that sounds like a teachable moment. Both residents should have parameters in place and the nurses should be giving the medications within those parameters. Unfortunately, it sounds like on my next visit I need to do some education and make sure parameters are in place. Review of the facility's policy Medication Monitoring Medication Management dated 09/10 indicated: Policy: In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use. When selecting medications and non-pharmacological interventions, members of the interdisciplinary team participate in the care process to identify, assess, address, advocate for, monitor, and communicate the resident's needs and changes in condition. Procedures: The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis. .2. Residents receive medications only if ordered by the prescriber. The medical necessity is documented in the resident's medical record and in the care planning process. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105714 If continuation sheet Page 7 of 7